Monday, 6 May 2013

Who is your audience? - Learning about burnout through social media

"The Rules"

Last week a new website appeared : The Moderate Doctor. The purpose of the website was to host "The Rules", which were originally described as follows

"The Rules have been developed to help patients maximise their experience of consulting a GP, and give GPs a chance to vent their frustration at the sometimes bewildering world of the consultation. For anyone of a sensitive disposition-do take The Rules seriously! I hope everyone can find some therapeutic benefit in them-doctors and patients alike."

So from the start The Moderate Doctor was pretty clear that this was meant to be satire, although I did suggest to him that he removed any suggestion that these would help patients because I didn't think that it would. And he did. However, less than a week after publishing the rules are gone from the website. Dr Moderate has said the he meant this as some fun but that it wasn't worth the 'vitriol' and 'grief' which he had received and the he could do without the 'GMC imitators'. Personally, I do not think that the GMC would be interested in this blog or twitter account and if someone thinks that they would, it probably means that they don't understand the guidance on social media. Dr Moderate was not breaking any confidentialities, or doing anything else that I think is in conflict with Good Medical Practice.

Audience

So what audience was Dr Moderate aiming for? He is a keen cyclist and he had based the his rules on The Rules published on the Velominati's website. Who are the Velominati? They are' cycling disciples of the highest order" who spend their days "pouring over the very essence of what makes ours such a special sport and how that essence fits into cycling’s colorful fabric".Their website is for those who are DEDICATED to cycling. Their rules might not make that much sense to the rest of us but it is pretty clear that the rules are aimed at those who consider themselves as Velominati, and only those. There is satire but they are laughing at themselves and their own healthy obsession.

Dr Moderate was trying to achieve something much more difficult. His rules were not aimed at making fun of a set of super dedicated GPs, but seemed to be aimed at bonding with other doctors through joking about their patients. It wasn't clear that the focus of the joke was the doctor. That made some people feel uncomfortable. One member of the public wrote replies to the rules in his own document as he couldn't fit them all into the comments. In general there was quite a lot of confusion about who the rules and the satire was aimed at....

When doctors quibbled about the rules they were often called into question the content not the tone of them. For example, this London GP replying on Dr. Rant's Facebook page suggests that for patients to bring lists is very useful as often problems are related. And a patient complaining of tiredness could have a serious condition so shouldn't be dismissed. I am certain that if the list had stayed up we could have had very interesting conversations about many of the ideas that they raised. But it's clear that Dr Moderate was reaching a more diverse audience with The Rules than he was expecting.

Do The Rules raise bigger questions?

There is much talk of GP burnout at the moment. If you are a UK GP can take a survey on the Pulse website to assess how you score for measures of emotional exhaustion, depersonalisation, and lack of personal accomplishment which are recognised features of burnout. Clare Gerada writes in Pulse that "‘Everything else has increased our workload. The insistence that perfectly healthy people “see their GP” hauls demand for access to an unreasonable level and casts us in a role that we have never asked for." One of the doctors who is sad at the withdrawal of the rules mentions that it was good to know that there were other doctors who felt the same about abuse of the service. So it seems that increased workload may be behind The Rules and behind the concerns about GP burnout.

Is workload related to burnout? A study of medical students who applied to medicine in 1990 (McManus, Keely and Paise, 2004) measured personality traits and approaches to learning at baseline, and then followed them up in their final year or medical school, their PRHO year and again a few years later. They found the personality and learning style at baseline, predicted feelings of burnout at graduation and approach to work 5 years later. Medical students who were more extravert, had a deeper approach to learning, were less neurotic, and more agreeable were less likely to report burnout, stress and exhaustion later, and then a more positive attitude to work and a greater sense of accomplishment later still. So does personality lead to stress and burnout which then leads to work dissatisfaction rather than the other way round?

But there is some confusion about burnout too. How important is it? Does it affect the way that doctors practice or communicate? Two studies suggest that it might not. A study in the US by Ratanwongsa et al (2008) measured burnout in primary care doctors and then taped consultations with patients, assessed them against the ROTER scale and measured patient satisfaction. Burnout was correlated with patients saying more negative things as an attempt to build rapport, but otherwise there was no correlation with patient satisfaction. And in the UK a cross-sectional study of GPs by Orton et al (2012) found high levels of burnout, but when consultations with patients were examined the burnout was not obvious to observers, and there was no correlation with patient satisfaction. So when the results of the Pulse survey are announced we will need to ask what the significance is.

Where can doctors tell their stories?

Cole and Carlin (2009) write in the Lancet, that burnout is "also a euphemism for what many physicians experience as a crisis of meaning and identity". One of the solutions is for doctors to be able to tell their stories and to be compassionately and non-judgementally listened to. Can social media have a role in this? Jonny Tomlinson's blog is probably one of the most potent examples of this. His latest post is on the impact that loneliness can have on patients and how they present to their doctors. Last year he moved many people, including me, with his post on how medicine, and we doctors. might make our patients feel shame. But his blog is only one place that he can tell his story. He has written about how he still meets every three weeks with a group of GPs who he trained with 11 years ago.

But social media is not somewhere that one can be guaranteed that one will be listened to compassionately and non-judgementally. Dr Moderate took quite a risk when he decided to share The Rules with the world. He has raised important issues and I do hope that we get the chance to explore them meaningfully. But at the same time I wouldn't blame him for wanting to avoid this space. I'll admit that my first reaction to his setting up a website to support one publication, which seemed to be based around a humourous denigration of patients, was not one of empathy or compassion. But perhaps it should have been.

31 comments:

The problem with The Rules is that they show GPs in a very bad light as arrogant, self-important and poorly educated.

The reason people feel uncomfortable reading The Rules is because these scenarios that doctors find so highly amusing actually have serious consequences for patients.

If you consider the TATT rule, fatigue is a major symptom of many diseases and should be taken seriously. In my case TATT was the only presenting symptom of what turned out to be T1 Diabetes - a potentially fatal disease. On each presentation of my fatigue I was dismissed repeatedly with similar comments as made in "The Rules" and told that I should find a "psychological coping strategy" if I felt tired all the time. It was amazing what a difference insulin made to my "psychological" tiredness when I finally got a diagnosis.

Similarly when it comes to lists of symptoms, there are various diseases that present with multiple symptoms (think autoimmune disease, endocrine disease etc.). There are so many patients (usually women) with MS, lupus, thyroid disease etc. who are repeatedly dismissed because presenting with more than "one" symptom is taken by doctors as a sign of mental health impairment. Sick patients stuck in this scenario really don't find it very funny.

As for burnout I think it is telling that other professionals who work in emotionally stressful jobs engage in personal therapy or clinical supervision as a matter of course, yet doctors feel they are somehow above seeking help and instead think it is acceptable to gang up together to deride and laugh at their 'problem' patients. Perhaps there should be more focus on recruiting emotionally mature people into medicine rather than academic boxtickers and hoopjumpers.

Doctors are paid very well - GPs in the UK are the second highest paid in the world - and could easily afford psychotherapy to help them with their emotional issues. I don't see why personal development isn't encouraged, rather than ganging up against patients (who after all have paid for the service through their NI contributions). Perhaps if doctors stopped stigmatizing mental health problems in their patients, then doctors would find it easier to seek help for their own mental health issues.

I noticed on Twitter that many doctors think that writing The Rules is an acceptable way to behave, using the usual bully's tropes "It's only a joke" and anyone who has a problem with The Rules "lacks a sense of humour". One day these doctors too will be sick, vulnerable and in need. Let's hope for their sake that they don't encounter a Dr Moderate in their time of need.

I think this is part of an ongoing conversation. Just this morning someone said to me that if I had never been irritated by something depicted in the rules then I was too good to be true. Of course I have been irritated sometimes but that is my issue not the patients. It's my professional responsibility to work through that irritation and if I have shown it to a patient to apologise.

Talk about burnout and frustration with workload has been around for a long time. We need to come up with some positive strategies on how to deal with it.

Should we be selecting for certain personality traits in medical students? I don't know. But I know that people are thinking about it.

We've no reason to think that Dr Moderate or the people who think that the rules are funny are not good clinicians who are kind to their patients. But I can understand why you are uncomfortable.

The issue here is one of perception and while we encourage doctors to share their human side and their personality, those who do so also risk exposing themselves to accusations of arrogance and lack of empathy. While Dr Moderate's blog may have been tongue in cheek and intended for an audience of like-minded doctors, what you publish online is widely accessible and also open to patients to read, comment and form their own opinions on. In the recently published RCGP social media guidelines it is noted that one of the risks associated with social media participation by doctors is the risk of engaging in behaviour which could be perceived as "unprofessional, inappropriate or offensive by others" . While you are right in saying that Dr Moderate doesn't breach any guidelines with respect to breaking patient confidentiality, I wonder did it breach a more intangible code of professional ethics? For me it highlights that we still have a way to go when it comes to defining professional use of social media.

I think that Dr Moderate is thinking over what his intended audience was. He very much did want this to be accessible to patients so it wasn't intended for just a group of like-minded doctors.

I don't think that voicing difficulties dealing with expectations is unprofessional. I'm not sure that it was inappropriate either. It certainly might be offensive to others. But I've often been told that no-one has the right not to be offended. I have mixed thoughts on that. Offending the powerful might be OK, but the weak and vulnerable, that's not on.

Dr Moderate probably did expect that others would read what he had written and not find it funny, or disagree, but I think he was taken back by the force of the response.

Openness and transparency means that we don't just present manicured profiles to the public. We have to be prepared to admit that all is not well in our communities and to try and come up with solutions together. It isn't going to be comfortable but work which is worth doing usually isn't.

Thanks for this outstanding overview on such an important issue, Anne Marie. The dear departed Rules are a compelling example of doctors who "just don't get it" when it comes to social media.

The surprising part of this story is that Dr. Moderate is surprised.

He's in good company. Consider the Rhode Island emergency physician who was fired by her hospital and reprimanded by her state medical board for posting comments on her Facebook page about one of her trauma patient. Even though she did NOT name the patient, she included enough detail that the patient could be easily identified in the community. And she did this for the "entertainment" of her peers.

Or consider the Michigan police chief who found this comment on social media from a potential recruit he'd just interviewed:

"Just returned from the interview with the Southfield Police Department and I can’t wait to get a gun and kick some ass.”

As you can guess, Southfield declined to hire him.

The trouble is, we don't want the people we trust to take care of us - like doctors or police officers - to be poor judges of what's appropriate and what's not.

Things that are funny when gathering at the pub or around the water cooler at work with your peers are just not that funny - or appropriate - when you make the decision to post them online for the entire planet to view. Particularly, as you are whether you practice medicine or work as a police officer, when those who are most dependent and vulnerable are listening in.

That's just basic common sense - and we patients expect a lot of that in our docs.

Both your examples are about breaking confidentiality. That is obviously wrong - everytime- everywhere- no exceptions. But that wasn't what Dr Moderate was doing. He was expressing his frustrations with general practice in the UK. And a lot of other doctors agreed. Both publicly and in private doctor forums. So the issue here is not the use of social media, it's that there are a lot of doctors who feel a disconnect.

What's the solution to that? To me it is not on to just tell them not to talk about this in public. The benefit of social media is that we CAN talk about this in public. We rightly expect a lot of doctors but if they are stressed out then we all need to think about how we can fix that.

So I really want to question whether what Dr Moderate did was appropriate or not. Maybe he took The Rules down because people said that they weren't funny. Maybe he thought that there were batter ways to address what the frustration that he felt. We don't know but I'd love if he came here and posted about it.

I'm no fan of censorship. Any view has a right to be expressed. And to be responded to.

Let's get on with working out solutions together rather than saying good riddance.

I think what concerns me most here is "that a lot of doctors agreed". If they did, then I think the practice of Shared Decision Making is a long way off from being understood. Personally, I would rather my doctor educate me in what makes a consultation run smoothly, in an appropriately professional manner.

You do however make a good point about Doctors being able to tell their stories. What happened to good old fashioned honesty - does everything have to be shrouded in black humour and sarcasm? Or maybe that is reflective of being afraid to speak out as an individual- easier to mock patients as a group, rather than say you are struggling to cope.

If doctors are suffering more burnout now compared to a few years back, I think it is about more than how patients act during consultations.

It's interesting though - I see very little of this black humour online from other professional groupings such as solicitors and accountants. Perhaps doctors as a profession don't have enough outlets to help them deal with stress appropriately?

Thank you for this response. I agree that if many doctors are feeling this is their truth then there is a bit of a gulf between what medical students and GP trainees are taught and what the reality of practice is. That's why it's so important for academics to engage in these spaces and try and gain insights and help, rather than to say that certain topics of conversation are off limits.

Why do so many people attempt to use humour to express themselves? I don't know. The literature on 'gallows hunour' which is quite specific, doesn't cover this wider territory, I think. How would we have responded if Dr Moderate and written honestly about his frustrations, but without pointing the finger at patients, who as you say are very unlikely to be the source of his woes.

And your point about support mechanisms is well made. That's why I made the point that Jonny T doesn't just use his blog for support- he probably gets most of that from the doctors he practices with, the group he meets with. He's using his blog to disseminate his learning.

Helping doctors to manage their emotions starts in medical schools. It's important. But, and maybe this is the root of it, there humour is often seen as a very appropriate coping mechanism. Hence the medical school revue. If this is a healthy way of coping, why don't we open these up to the public too?

Satire is a form of criticism and anyone who uses it should be prepared to get barraged with emotional responses. Especially when the criticism is targeted at another group and poor behavior by the writer's group is defended. Dr. Moderate does both.

I believe when the writer chooses to use satire in this way, it automatically gives the reader license to be offended.

However, burnout can't be ignored and finding ways GPs can avoid and overcome it is important. If this was Dr. Moderate's goal he could have used satire that points out the negative consequences that result from GPs working long hours, missing commitments, eating poorly. not actively listening to patients, and losing sleep. Of course, he will now be attacked by some GPs for being insensitive to their situation...But done right could also open their eyes to the dangers and initiate a great conversation about potential solutions.

Dear Dr ModerateI have taken the time to read your Rules and hope you will do me the honour of reading my reply. I have tried to copy your dry style. It will be interesting to know how you feel after reading my response. Like your own blog post, it has not been written with any ill intent though no doubt I shall raise a few entrenched eyebrows from those who misunderstand my wit.

1. Turn up on time.I promise to always do my best. Ninety-five percent of the time I will arrive on time even if I am on crutches & blind in both eyes. Oh dear! I seem to have added 'fear of upsetting you' to the 'list' of my symptoms.

2 Get to the point.Please place a sign on your door stating that you might not be interested in anything I say, so that I might know in advance to bring a 'written' list.

3 ListsHow will you diagnose my life threatening mega-multi-symptom B12 Deficiency in 'ten minutes' if I do not bring you a list? http://www.b12d.org/b12-signs-symptoms-assessment

4 Homeopathy I promise I will, of necessity, only defer to a homeopath if I find you are rubbish at your job.

5 Man-upThis won't be necessary because without your diagnosis & correct treatment, I will become demented and will not know that I am ill.

6 Newspaper Cuttings I agree not to bring in newspaper cuttings because you have trained for twelve years and read every credible journal that has been published and keep yourself completely up to date in every discipline.

7 Moaning about Hospitals Why indulge you?

8 Bugs For 'is there a bug around' read 'I have been scared witless by the media & need to justify why my head-splitting undiagnosed B12d migraineous headache isn't meningitis". I can't ask you outright because you will think I am a hypochondriac.

9 ReferralI will think of a better way of trying to say "You make me feel guilty for taking up a few minutes of your valuable time so I will try and placate you straight away by asking to see a specialist, thus saving you the bother of trying to diagnose me". Win-win.

10 Tired all the timeRead "You have not been taught tired-all-the-time is a well documented, physical symptom of widespread undiagnosed B12 Deficiency". This is 'evidence' that you have not been reading the BMJ with intent to improve your practice: but how could you when your working hours are plainly over-tasked. (Truly, I know that they are!)

11 Absolutely agree. I don't want to waste one second of the fifteen seconds you spend listening to me before you label me as a MUS patient and return to your QOF. Incidentally, MUS means "Many 'Undiagnosed' Symptoms'' of B12 Deficiency. Training opportunity identified. Marvellous for Revalidation I would think.

12. Own your own heathWe do! That is why sometimes, on the rare occasion we recognise your lack of knowledge or willingness to listen, we ask for a second opinion.

13. Depression is an illnessAbsolutely, and other than in a few presentations such as grief, it is a physical illness and occurs on breakdown of the methylation process. It's duration is directly linked to the deficiency and/or metabolism of essential vitamins and minerals plus genotype thrown in. But of course we wait for EBM to catch up as usual, so carry on dishing out the anti-depressants which in turn clobber our finely tuned metabolism.

14. EntitlementAre you quite sure you wouldn't be happier in a private research post if you have no wish to provide a "service" that is free to all. Entitlement is at the very core of NHS and as a nation we are proud of it. Are we being given false information at the ballot box? (Irony, in case anybody didn't grasp it.)

15 ScansBut the media tells me again and again that you miss our tumours until late stage, Dr Moderate. Jonny down the street and my homeopathy practitioner are case in point! Are you seriously telling me you have never misdiagnosed a patient? Dear Dr, when I ask for a scan, all I need is a minute of reassurance, not an exasperated sigh.

Bless you young Doctor Moderate. I hope you are young because you will have opportunity to improve your communication skills to match your technical ability. I bless you because far from doing your profession a disservice yesterday, in a roundabout way you have also acted as a catalyst for change. We may yet live to owe you a fine debt of gratitude.

For you see your Rules did not need spelling out to Patients. Many already recognise these Rules, in practice, in many surgeries all over our Great British Isles! Does this surprise you?

You have shown in one monumental faux pas that it is indeed time that both Patients and Doctors found a middle ground in beliefs and expectations of one another. Notice that I also gave Patients a capital P. Please understand the important message this capital P conveys. The Internet has redressed the power, Dr Moderator. Twitter is the Great Leveller.

Fear not, your profession is still held in the highest esteem, especially by me, but it would be injurious to your own state of mind if you believe yourself to be set apart like Doctors in the not too distant past. By venturing onto Twitter, Patient Opinion has very swiftly become both your tutor and your student. Learn to nurture our talent, to compliment not hinder your own.

The people that should re-balance General Practice within our communities are the people that have lived on both sides of the fence. Not the psychiatrists or sociologists because their view is too narrow and, of necessity, tainted by protectionism. The Wounded Healers and gifted GP diplomats should step forward to lead General Practice to a place befitting this latest SoMe modern age. It is fundamentally clear that both Patients and Doctors have much to learn from one another to ensure continuity of pride and efficiency in our greatest and much loved institution.

So kindly then and with gentleness, for I know you have reason to lick your wounds having faced such a public flogging, I ask you to read this blog by wounded healer GP David Lewis. It will help you to understand why your "Rules" had to be taken down. Your huge burden of MUS Patients, Dr Moderator, are waiting for you to listen, learn and help them back to better health.

For those who know me on Twitter, I am fond of a little joking here and there, which reflects me in RL. My points are perhaps general, but I hope can be related to the case in hand - you will have to do that dear reader as I am too lazy to be that clever tonight...

I’m fortunate. As a proper Doctor (PhD), I don’t need to worry about the GMC/Stazi knocking on my door, although there have been times when I have said the wrong thing in jest; e.g. jokingly telling my (elderly) future mother-in-law (who is Italian) to ‘vaffanculo’. (Don’t worry; we have long since let that lie). Anyway; despite the crap of modern day austerity ridden Britain, ‘lachen IS gezond’ (laughing IS healthy). But everything is sooo play-it-safe these days; especially in medicine and research, which are of course serious and can sometimes be life-saving business. (Don’t get me started on my doubts re EBM!) BUT... and here is the mahussive paradox. We sit on this tiny rock in an immense and meaningless universe. It’s absurd. We need humour to correct this literal cosmic imbalance. Albeit in appropriate places!

The above views are my own and do not reflect the opinions of my elderly Italian mother-in-law; or indeed my own mother.

"Albeit in appropriate places" - well that is the crux of it, isn't it? What is the appropriate place?

And just to clear this up it is NOT about the GMC. I've tried to stress that in my post. It's about us talking about what is acceptable. I'm seeing quite a few people saying these conversations should happen behind closed doors and I'm trying to explore the pros and cons of that for writer and reader.

I don't think Dr Moderate intended harm by the site. While I struggled at first to see if it was meant to be serious or comedy, it is clear now that it was intended to be satirical. I think it would be wrong to conclude that Dr Moderate is an arrogant or uncaring doctor in real life - nothing I have seen from subsequent tweets would lead me to that conclusion. Most doctors will have indulged in this sort of humour at one stage or another - usually over coffee after an exasperating surgery.

There are two issues here for me - one is what we think about this sort of humour, and the other is whether there is a time and a place for it. Many people would see this humour as harmless, and perhaps a useful insight into the unique world of the consultation. For many doctors this sort of black humour has been used as a way of venting frustrations and 'staying sane' over the course of their career. I can sympathise with this, although I am not convinced that it actually helps us deal with the stress of the job. How I think about my patients will affect how stressful I find it to work with them. If I learn to denigrate the patient with 'the list' - even through humour - then I will associate the list with frustration and annoyance when I am faced with it in the consultation. If instead I can see the list as a positive challenge, maybe I won't get that sinking feeling when I see it coming.

One of the greatest challenges - and most rewarding aspects - of the GP consultation is to nurture an unconditional positive regard for the patient. It needs work and constant care to keep this attitude, since our personal prejudices, frustrations and limitations mitigate against it. For me, speaking well of patients is a vital part of my efforts to maintain this attitude, and so I have always felt uneasy with the sort of humour that does the opposite.

It takes all sorts, however, and I recognise that some doctors find this sort of humour releasing, as it makes them feel less isolated in their frustrations. The traditional domain for this in the written word has been the GP magazine. Aimed at doctors it is not intended for patients and so cannot harm them directly (whether it harms or benefits them will depend on the effect, if any, it has on the doctor's attitudes and behaviour). The reality of our social media-dominated world, however, is that even these are not longer private for the profession. Any website can be tweeted, and unless it is behind a doctor-only wall it could be seen by all. Some patients may well be even more offended if they feel that doctors have been 'laughing behind their backs' all these years.

The problem with this site was that it was put straight out there, for all to see, and seemed to be intended for both doctors and patients. I think this was just misjudgment about the complex mix of doctor, patient, allied health professional, journalist etc that you get on twitter, but it meant that it seemed so much more out of place than in a doctor-only zone.

The Rules have been described as satire. For me, satire depends on who is laughing at whom. Classically it is the public, with the help of comedians/writers, laughing at the powerful - such as politicians or celebrities. Here we had a doctor (powerful) laughing at the patient (vulnerable), which is the biggest problem I had with it. It gave the appearance of arrogance and a lack of regard which painted the profession in a bad light and was likely to offend patients. It is rather like racist jokes - a black comedian can make jokes about being black, but it is sickening when it is a non-black comedian doing so.

It could be argued that it was simple observational comedy. Again, for me, it depends who is the joke teller. For a comedian who is not a doctor to laugh at the way some patients behave when they visit their GP - and how some doctors behave in return - there could be genuinely funny, non-offensive humour which might even give valuable insights into the consultation. Maybe Michael Mcintyre will take it on one day!

Thanks Martin for articulating all of that so very well. I am perhaps less concerned about the profession being 'painted in a bad light' as I think that the fact that we have discussion about it, and can challenge it means that there is not one clear view on this. It perhaps paints on as a profession with doubts and uncertainties but I think that is the truth of it. I still stand by my feeling that patients judge us (mainly) by how they find us as individual doctors caring for them.

So for now I think it is right and proper that we have debates like this in an open and honest way.

Since he did not violate individual privacy I say let him use social media as he sees fit. Though it does seem like he is having a change of heart. He wanted to publish his rules to show how clever he was but it only showed him to be a cold, cynical, jerk.

This should not be made to be larger than it is. It does not represent the majority view expressed by doctors in social media. The whole episode comes across a bit sophomoric and I have a hard time thinking of a larger lesson from the whole experience besides, the obvious: the internet is big and public.

When you are writing online you are doing it 20 foot letters and in permanent ink. Beware.

I think you are a bit too quick to dismiss this. If Dr Moderate had just made a silly faux pas then you are correct - there would be little point in talking about it any further. We all make mistakes. We hopefully all learn from them.However, The Rules have had quite a lot of support from doctors in a private doctors' forum, and publicly from doctors and others on Twitter, and on Facebook. Yes, most of these doctors might not have as extensive a presence online as you or I, but I think it means that we should pay a little bit more attention to the underlying issues.

I don't happen to think that Dr Moderate is a cold, cynical jerk from what I have seen him of his online interaction with myself or others. I'm still not clear what he did hope to achieve with this, what he thought the consequences would be. Maybe we will learn more about that eventually as he digests what has happened himself.

But in the meantime I think we can have a conversation about whether exposing the 'warts and all' is a good thing for medicine, or whether we even have a choice.

Part 2:Just a couple of thoughts from across the water-not from twitter but from other respondents:“The 10 minutes I spent reading and circulating The Rules yesterday were a humerous highlight of my day shared by medical and non medical friends alike. Of note this day included seeing 40 patients, many of whom did come out with the good old 'is there a bug going round?...I've got a pain in my ovary dr...and I just need a couple of referrals' lines. Did I bring shame on the profession by ranting at them and turning on my facebook page? No of course I didn't - I chuckled to myself, smiled politely and carried on. That's what we do. Its just a shame some people can't stop to realise that before taking umbrage at a comedy moment intended to offer light relief to the daily challenges and frustrations that we all face.”And another from doctors.net: “A thoughtful essay about this (for the cardie brigade?) here: http://wishfulthinkinginmedicaleducation.blogspot.co.uk/2013/05/who-is-your-audience-learning-about.html”The cardie brigade? Is that how the average GP views academics or people who object to satire/humour?Where does that leave us? Where does it leave me? Am I a cold, cynical jerk ? I wouldn’t describe myself as such, my colleagues don’t offer up that opinion, and I still have some patients who see me on a regular basis. I think it is possible to be a “normal GP” and still have some views, or a warped sense of humour, without it impacting on everyday patient care. Maybe I am wrong-one point here is that we all have different views, but if we air them publicly, we can expect public debate.What next? Apologise and learn-that’s what I teach my children, so a dose of my own medicine is in order. I have certainly learnt. I will certainly learn more-this has opened me up to the world of academics as well and I am quite enjoying that aspect.So to all of you, patients and doctors, who are upset with my humour, comments and opinions, I apologise. It may be that I have inadvertently started a wider debate but I certainly did not set out with that intention. I also specifically did not set out to undermine our relationship with patients which I, too, value highly. First, do no harm. I apologise if I have harmed.

Thank you very much for your thoughtful responses here. I realised a few years ago that there is a gap between academic medicine and people in practice, and I think that both sides need to address that. The cardie brigade is probably quite polite compared to some of the things that I have seen in the past over on DNUK and elsewhere!

I'm firmly of the opinion that social media is one of the ways that we can address these gaps. As such I have devoted a lot of time to trying to explore the opportunities for conversations. We are in the middle of trying to establish an online journal club which I hope will bring together public/patients, non-academic health professionals, and researchers. You would be very welcome to join us in that project. I have also been leading some discussions about medical education on Twitter and elsewhere (ie a fledgling google plus community!) And in all of those discussions we try to bring together people from many different perspectives. And to learn from each other. This is challenging work but I think it is worth it to hear from so many bright and committed people.

Hopefully, things will settle down and we can get back to discussing what is really important- how can we help our patients as well as possible? How do we cope with competing demands? How do we stay through to our values? To me the underlying issues are much more interesting that the use of social media itself. And we have to watch out for people who distract us away for that.

It's quite possible to have respectful conversation. I tend to publish all comments here but feedback when I disagree. As you say that is the nature of public debate.

If there is any way that I can help you please do get in contact,Thanks again,AM

Part One:Thank you for a thoughtful, and thought provoking article. Here I come-into the lion’s den….The Rules were created by myself as I put in to writing ideas and feelings that have built up over the years. There was no real agenda-just my own thoughts and I felt many other doctors would be able to identify with them. I shared them with close colleagues first, they even added some suggestions and I was encouraged by them to share with a wider audience. The idea was for us (the average GP) to be able to say-“yes,I do sometimes think that, am I alone?”I put my head above the parapet and asked for comments-boy did I receive some. Straight from the bell, an uppercut, almost a knockout blow:“Was it your "over 8 years of training" that made you an arse or was it a pre-existing condition ?”Ouch..wasn’t quite expecting that. Are people taking these seriously? Do they really think that these Rules are to be obeyed by doctors, or represent how we interact with patients? Are people being oversensitive or am I being insensitive? Have I strayed into forbidden territory-the doctor/patient relationship as a point of humour/satire? Some commentators clearly think so and I respect that-I may not entirely agree but that is one of the difficulties of an online presentation, it can be very one dimensional at times and this is where the audience becomes vitally important. Oh, hindsight is a wonderful thing..Twitter got hold-opinions were shared and I found this “enlightening”. I had not participated in Twitter before this-I suppose what surprised me was the views I was hearing there, largely did not seem to correspond to the views expressed to me privately, or on “closed” forums such as doctors.net (where I am also not a regular). What did this mean? Others here are better qualified to make that assessment, but to me it is interesting-some doctors less willing to share publicly a view that might be viewed as off the beaten track? Loud, confident voices on twitter with many good, sensible arguments-how does one obtain a balanced view from society/doctors at large? The answer may lie in combining the two-that will be a difficult bridge to cross I feel.

"Apologise and learn". Well, you can learn; but sometimes all you learn is that the internet and the responses from Twitter are unpredictable, and people are all too happy to write rabid responses against a caricature of what was written.

Apologise in many dictionaries is defined as "expressing regret as something one has done wrong". I hope you mean that you would say you were sorry if anybody was genuinely upset (and I suspect many more enjoyed the frisson of having a go at something they hadn't bothered reading properly or considering the context of); but are you sure you've done anything wrong? I'm not!

But are the responses unpredictable? As Roger Carr suggests above (and you won't have seen his comment as I missed it in moderation until now) the response to The Rules was not so unpredictable.

I think that you are doing a disservice to those who have commented here and elsewhere on why The Rules made them uncomfortable by saying that they just hadn't bothered to read properly or consider the context. I don't think that this is fair.

I don't know how you would establish if someone is 'genuinely upset'. But it seems reasonable to take online feedback in this case at face value.

Wow I missed this completely. (Sorry, I've got this whole "sequester" to yell at the USA Congress about!)

1) If patients think that the MDs are condescending to them, then they should hear what us PhDs say about the medical students we teach and grade. Heh.

2) MDs should never expect themselves to be "perfect", I've seen a lot of good kids burn out that way. If you desire perfection, go be an engineer. Or a mathematician. We've still working on physical models for evidenced based medicine.

3) If you do not enjoy talking to sick people, most of whom do not have any higher education, please don't become a medical doctor. There's a shortage of statisticians right now, if you're introverted and obsessive about correctness I'd hazard to guess this will have a lucrative and stable career for you.

4) If you get off on always being "the smartest kid in the room", please don't be a medical doctor. Compassion and empathy are required for practicing medicine. Not an ego-driven desire for respect from less-educated folks. (You see this a lot in politicians as well.) In graduate level physics courses, it's the job of the professor to continually remind genius-level students that they hardly know anything at all about the way the universe works. These kids are far more intelligent than the vast majority of medical doctors- and part of their training involves routine lessons in humility.

OK. I'd best get back to my nation's current crisis. -Dr. Allison L. Stelling, @DrStelling

I'm a relatively new GP (CCT'd in 2010 after 11years training) but of a generation who grew up with the Internet and built much of it.

Ive been using Facebook for 8+ years and mobile phones for 15+. I remember Demon Internet, CompuServe and AOL chat rooms. I’m now interested in building doctor-led online resources and improving clinical connectivity.

I think the doctor vs patient online behaviour debate is a bit of a red herring. It makes the basic presumption that doctors and patients are 2 separate entities. They are not.

We are *all just people*, in separate locations, tapping on various bits of hardware, to generate text on software, held on remote servers, in an attempt to communicate with other people we don't know very well. Doctors are just people who have taken a specific interest in healthcare in life but they may equally or more so be patients.

@Dr Moderate – you seem to have genuinely been posting a piece of humour/catharsis which got a bigger backlash that you thought or ever intended. I do not believe that you set out to harm anyone and indeed it catalysed a really useful discussion. Will you be staying online?

Perhaps 'Big White Wall' is better suited for clinical catharsis and for me this underlines how careful doctors need to be when making comments online, particularly if they are about patients.

Martin Brunet makes an especially pertinent point regarding the doctor being in a position of power and the patient a vulnerable one. As he says, humour tends not to work along a high-to-low power gradient, especially in a public setting and it seems this is central to the online backlash received.

Personally I feel that Dr Moderate's ‘Rules’ demonstrate the black humour that exists at the very heart of medicine. It's what allows us to continue to function under horrific circumstances- laugh or develop PTSD...

Parts of this YouTube clip: http://youtu.be/QB4L6m_OqYs from the recent TEDxBOW event (#fromtheheart) speaks of tragedy being at the heart of laughter and it chimes particularly true in this case.

Andrew Carnegie said:"As I grow older, I pay less attention to what men say. I just watch what they do."

The truth is that doctors see many patients everyday requiring multiple diagnoses and management plans with follow up as necessary. It’s a lonely job and requires a lot of emotional expenditure; frustration is inevitable if you believe in transference. Whatever our words, online or otherwise, for the majority our actions demonstrate the deep care we have for our patients.

Many of my peers feel that consultation room mismatches are not to do with patients and doctors per se but the environment/pressures of the NHS that predisposes to fractious relationships and 'burnout'. A symptom of the latter is ‘depersonalisation’, which is described as a tendency to depersonalise those with whom one is forced to interact, so that patients are seen less as individuals and situations become simply part of a routine. Is ‘The Rules’ a manifestation of this Dr Moderate?

What crops up frequently in healthcare is 'communication problems' and whenever I think communication is a problem I wonder what question is trying to be answered.

This, I feel, Anne-Marie sums up beautifully in the first line of her blog and it's a question we should all ask ourselves before submitting our thoughts to the online ether:

Great discussion here and on twitter, thanks for collating and genuinely furthering the debate Anne Marie, and of course @DrModerate for kicking it off in the first place. I've commented before, as a non-medic, on my understanding that healthcare staff are as human as the rest of us. I came to The Rules very late, and it may have been because their reputation preceded them that I didn't react as badly as I might have been led to believe. What's wrong with humour? There was nothing personal or confidential, I had assumed it was someone sharing their reflections with some collective support - so sort of documenting what a few people were thinking.

I guess my reflection is that so much of this comes down to perspective. As far as I could tell, on a quick reading, this was intended as humour, perhaps with some genuine learning in there depending on your baseline knowledge, and most professions share satire like this. It may also depend on who you mix with, a lot of my friends are in the armed forces where banter is a prerequisite coping mechanism (irrespective of rank) and where no-one would bat an eyelid at this sort of humour. I guess I wasn't offended personally, and given his comments above I'm confident that @DrMod never meant to offend. That said I appreciate someone with a different perspective may see the world, and the rules, quite differently.

What did surprise me a little was the response to this (supposed) social media faux pas. The insults, vitriol, abusive comments, the general lack of compassion shown towards Dr Moderate - at one level hugely ironic, at another slightly worrying given how quickly the social media machine congregates and dishes out virtual punishment or insult to those who have wronged it. Ultimately we're all humans and therefore fallible, perhaps more compassion towards Dr Moderate, and any others who hold an alternative viewpoint to our own, would get us to a greater understanding.

Thanks again Anne Marie for facilitating that wider discussion, George

Hi everyone,There are some great, thoughtful comments here - it's quite inspiring/reassuring to see that opening these kinds of issues up for debate on twitter can actually lead to better understanding and dialogue, not just a shouting match or a blame game!

I think it's bang on that the issue here is about audience - I certainly don' t think having humour-less doctors is a way forward, or even that doctors shouldn't be able to express these kind of issues, but I think in this case two issues are important: 1. That 'The Rules' was written 'at' patients - even if this was just stylistically done for fun, it still to my mind changes it into something done to or about patients, rather than being just about sharing experience/letting off steam/having a good moan with other doctors. 2. Social media is increasingly used as a way for patients and professionals to meet on equal ground and to engage with each other. Putting this kind of content on a public website and on twitter seems to go against this - I genuinely think many patients are quite fearful/anxious about their relationships with their doctors, and to find this online I think would be a real step backwards.

Lastly I'd just like to say a huge thank you to Dr Moderate for engaging with this - I think it's really admirable for someone to take criticism on board and respond so thoughtfully.

Hi Anne Marie :)You asked me on twitter if I'd like to comment on your post about Doctor Moderate's 'Rules'. I'd already expressed from a patient's point of view that I found the humour unkind (if not cruel), unhelpful to the patient/doctor relationship and that it confirmed my worst fears about 'some doctors'. http://www.twitlonger.com/show/n_1rk2fm9

To be honest I've had trouble formulating a response since the social scientist in me sees so much that the document reveals about social interaction, power relationships, new social media and the unprecedented effect of digital networks on the spread of information. The latter I feel very few of us have really grasped the full significance of. Information spreads instantly on the internet, like wildfire, and there is an absence of natural boundaries to contain it, comparative to those which normally constrain conversations to between the like-minded in the physical domain.

Twitter, particularly, connects me across its ever expanding branches to people whose opinions I would never in the non-digital world be privy to. Some of them are doctors, whose varied responses to 'The Rules' were enlightening. Those who felt discomfited were obviously the more empathic and compassionate towards the predicament of patients. Others who dismissed it as humour, or found it amusing simply recognised it for what it is, the means by which tensions, frustrations and resentments are defused among peers. It happens in every form of work. The public transcript (or performance) versus the hidden (or backstage) transcript. There's a popular saying in cyberculture that 'information wants to be free', and that is now happening at an unprecedented speed and scale, as the responses to 'The Rules' has demonstrated.

I find this particular example fascinating, since what we have here is an exposed hidden transcript which reveals that the powerful (the doctor) experiences a sense of oppression by the powerless (the patient). This is expressed as an intolerance for the unsophisticated, fumbling means of providing data, and demands that the, now more informed, patient makes.

I might feel sympathy for Doctor Moderate were it not for that power differential. They say that privilege is blind to itself, and I think that's true in this situation, and that many people who hold power do not realise they do. Coincidentally I recently came across the transcript of a talk by Clare Gerada in which she said that very same thing. That it was only retrospectively that she had learned to recognise when she occupied a position of power. https://www.nwpgmd.nhs.uk/sites/default/files/Clare%20Gerada.pdf

I've also read in recent times a doctor's account of her dismay at her loss of agency on becoming a patient herself, at being excluded from the dialogue about her illness and being at the 'mercy' of someone else making objective decisions about her own subjective illness. You ask 'Where can doctors tell their stories?' In light of Dr Moderate's list I reply 'Why can't patients tell theirs?'

You speculate that Doctor Moderate's 'Rules' may be a reflection of 'burnout'. But that's not due to the patients. Perhaps he could have constructed a list which humorously addressed the government policies and structural forces which causes doctors' empathy to become eroded over time. That would have required courage though, because those are elements which have power over him. Far easier and safer to direct his resentment at the weak, which is sadly an increasing trend in broader society under this present government.